Risky Business: Pregnant in America

Pregnant? Or think you’d like to be pregnant sometime and give birth in the United States?

You may be taking more of a risk than you realize.

Pregnant women in the United States have a greater risk of dying from pregnancy- or childbirth-related complications than women in 40 other countries around the world – and this risk is increasing. If you’re African-American – regardless of income level – your risk of dying from pregnancy- or childbirth-related complications is nearly four times higher than for white women in this country.

According to a new report from Amnesty International, Deadly Delivery, the state of maternal health in the United States is nothing short of a violation of women’s basic human rights.

Two women die every day “from pregnancy-related causes” but as the report notes this statistic doesn’t begin to address the 68,433 women in 2004 and 2005 who experienced “near misses” – the women who skirted death during pregnancy or childbirth. Or the 1.7 million women from 1998 – 2005 who experienced “adverse effects” on their health from a complication arising from pregnancy or childbirth.

Because the United States does not have any federal reporting requirements on maternal deaths, the report notes that “the number of maternal deaths may be twice as high.” The United States goal to reduce maternal deaths to 4.3 deaths per 100,000 live births by 2010, codified in the U.S. Healthy People 2010 objectives, has been met by only five states thus far. The national average now stands at 13.3 deaths per 100,000 live births. Being a pregnant woman in New York City may mean putting ones’ life in the hands of the maternity care business – 83.3 women die for every 100,000 live births. And California? It is now more dangerous to give birth in California than it is in Kuwait or Bosnia according to trends tracked by the state’s Department of Public Health.

Perhaps one of the most chilling bits of information in the report is that, according to the Centers for Disease Control and Prevention, approximately half of these deaths are preventable – a truth that leads Amnesty to declare that what we’re talking about “is not just a public health issue, it is a human rights issue.”

The five main causes of maternal death in the U.S. are: embolism, hemorrhage, pre-eclampsia and eclampsia (diseases associated with high blood pressure), infection and cardiomyopathy (heart muscle disease) but many of these can be treated if detected early on, even before a women becomes pregnant in certain cases, with adequate access to quality, non-discriminatory health care. In some cases, these conditions can be warded off completely.

“…the result of systemic failures, including barriers to accessing care; inadequate, neglectful or discriminatory care; and overuse of risky interventions like inducing labor and delivering via cesarean section. “Women are not dying from complex, mysterious causes that we don’t know how to treat,” says Strauss [Nan Strauss, a co-author of the report]. “Women are dying because it’s a fragmented system, and they are not getting the comprehensive services that they need.”

These “risky interventions,” such as delivering via c-section when it’s not necessarily needed, have led to a rising cesarean section rate in this country – a rate which has far surpassed being risky, actually. One out of every three births or 30 percent are via c-section placing this country’s rate firmly in the realm of “harmful” as per the World Health Organization, which recommends that no more than 5-10 percent of all births result from c-sections. In addition, as Block notes in her article, the NIH recently convened a panel of experts on maternal health – a panel which came to consensus on the importance of allowing women increased acess to VBACs or vaginal birth after cesarean sections. Current policies too often bar women from a vaginal birth after a previous c-section, increasing the number of c-sections, which lead to more maternal health complications.

On the cusp of comprehensive health reform efforts, the Amnesty report’s focus on the disparity in access to care between women who have insurance and those who do not is timely. Universal health care access is, for all purposes, off the table but Amnesty International sees the provision of care to all Americans as integral to a government’s role in preserving human rights:

Governments have an obligation to respect, protect and fulfill these and other human rights and are ultimately accountable for guaranteeing a health care system that ensures these rights universally and equitably.

Though Medicaid covers 42 percent of all births in the U.S. bureacratic barriers stand in the way of accessing care:

‘If you go to apply to the medicaid system, you need a “proof of pregnancy” letter, with the due date, the date of your last period, and the gestational age of the baby. Where do you get that kind of a letter? – a doctor. if you have no medicaid, how are you going to get to the doctor to get that letter?’ Jennie Joseph, certified professional midwife, Winter Garden, Florida

Even a woman with insurance is not immune to discriminatory practices by insurance companies, with policies that exclude maternal care or do not provide coverage unless the pregnant woman had insurance prior to the pregnancy.

The crisis only deepens for African American women. Far from being a question of income level or socio-economic status, the health disparity that exists between White and African American women when it comes to maternal mortality is more insidious. The disparity between white and African American women hasn’t changed in more than twenty years.

Womens enews, in their ongoing series on Black Maternal Health notes that,

African American women are three-to-six times more likely to die during pregnancy and the six weeks after delivery than U.S. white and Latina women. That holds true across various levels of income and education. In fact, some studies find middle-income and highly educated African American women at higher risk.

While women of color are less likely to enter pregnancy healthy and far less likely to receive any prenatal care than white women because of issues of access, many are now beginning to acknowledge the effect “chronic racism” has on a woman of color’s physiologic system, creating an environment ripe for physical problems such as high blood pressure and obesity.

For Native American and Alaska Native women, the issue may be more economically rooted. The report notes that while the U.S. spends $5, 775 per person on health care, the Indian Health Services spends only $1,900 per capita.

The report recommendations for addressing the state of African American, Native American and Hispanic women’s maternal mortality rates include “ensuring equitable access to health care without discrimination” by, among other things, increasing funding for the Office of Civil Rights within the Department of Health and Human Services.

The Amnesty International report is not the only call-to-action released this year on our crumbling maternity care system. According to the “2020 Vision For A High-Quality High-Value Maternity Care System” which was released in January of this year to address ways in which our maternity care system must be overhauled to address our maternal mortality rates, the United States spends $86 billion a yearon maternity care, and more money per person on health care than any other nation in the world. The report and accompanying “Blueprint for Action” calls on the U.S. government and our health care system to question what kind of return-on-investment we’re really getting for all of the money spent and makes key recommendations including: confronting payment reform; disparities in access and outcomes of maternity care; coordination of maternity care; clinical controversies (such as homebirth, VBACs and elective induction), and consumer choice.

To confront the crisis Amnesty International is calling for a major U.S. government intervention. Some of these recommendations include: removing “barriers to timely, appropriate, affordable” maternal health care; ensuring access to family planning services (which would also mean increasing funding for the federal Title X program which funds our community health clinics); ensuring women receive quality postpartum care; improving accountability in reporting requirements and, most timely of all, integrating a “human rights” perspective into our health care system – a step which would require a tremendous overhaul to our current, national health care reform proposal which includes no provisions for universal health care.

Finally, as Block notes, “Amnesty is calling on Obama to create an Office of Maternal Health within the Department of Health and Human Services to improve outcomes and reduce disparities, among other recommendations.”

With two in-depth reports released within one month of each other calling on our federal government to act quickly, this is our hour of decision. Our advocacy and health care experts have done the prep work. Now, President Obama and our congressional representatives must lead the charge.

Our maternity care system is broken and we’re paying for the damage with womens’ lives.

My daughter is a RN and she has worked in Labor and Delivery. Only black mothers were the ones who came in already in labor and never having seen a doctor during their pregnancies. We have several free clinics in our town so there is no reason for anyone to not have had prenatal care. It saddens me deeply to see the obituary column and note the high incidence of black infants who die very early in life. this is a crisis we must do something about and education is our only weapon.

jgbeam

Now THIS is what I call reproductive health care. Reducing mortality rate for pregnant women, and thereby their babies as well.

Jim Grant, Pro-lifer

marthanieset

Mea, What your daughter has seen in her L&D experience is likely related to the issue of access for these women, a service being free does not always mean that people have access. Having knowledge (or education as you point out), transportation, time and energy are factors as well and important things to be aware of as we try to create solutions to improve access for women of color.

The author or this article points out that these unequal outcomes for African American “holds true across various levels of income and education. In fact, some studies find middle-income and highly educated African American women at higher risk.” This is an issue related to racism that these women must face everyday.

Education is important and as this article points out, it is only PART of the solution.

amie-newman

wholeheartedly that reducing mortality rates for pregnant women and newborns is critical. But the methods proven most effective to do so are often fought tooth and nail by pro-life leaders. Also, there are few (if any?) pro-life organizations that cite improving maternal and newborn health as a key goal. When we know, from evidence, that these things drastically improve maternal mortaliy rates: increased access to family planning, increased access health care overall (which means, really, universal health care), and ensuring that all women – including undocumented women – have access to quality prenatal care, why aren’t the leading pro-life organizations supporting these efforts?

Pro-life leaders are focused solely on criminalizing abortion – one reproductive health issue for women. And, I should note, safe and legal abortion is key to reducing maternal mortality rates around the world. Unsafe abortion is a LEADING cause of maternal death in countries where abortion is illegal.

I love that there are issues related to women’s health and rights where those who call themselves pro-life and those who call ourselves pro-choice can agree but I admit that I don’t trust the pro-life movement per se to do much about the maternal health crisis because they are so committed to criminalizing abortion above and beyond anything else – continuing to put women’s lives (and, amazingly!! – newborn’s lives!) in danger.

jgbeam

I know of no pro-life organization that is seeking to criminalize abortion. If you are talking about overturning Roe, yes, that is a goal, but no one would expect that to result in prison sentences, or even fines, for women who have abortions! I may be misinformed but if you can refer me to a pro-life organization that advocates criminalization of abortion I would be interested. The only ones I know of are just as concerned about the health of the mother as they are in saving the unborn. Of course “Unsafe abortion is a LEADING cause of maternal death…” We oppose unsafe abortions as much as you do.

Jim Grant, Pro-lifer

amytuteurmd

The Amnesty Internation report is a POLITICAL report, not a medical report. It was created by interviewing focus groups, and prominently features the opinions of fringe homebirth advocates like Ina May Gaskin. And, of course, it is being publicly promoted by homebirth advocates like Jennifer Block.

Amnesty mentions, but fails to address the changes in reporting of maternal mortality. For years, it has been understood that reporting methods undercount maternal mortality. In 1999, the CDC expanded the categories of maternal mortality, and in 2003, the CDC revised the standard US birth certificate to ask specific questions about maternal mortality. The result can be seen in the graph below.

The 1999 coding revision and the 2003 birth certificate revision captured more maternal deaths as they were designed to do. Together they account for 80% of the observed increase since 1998 (5/100,000 out of a total change of 6.2/100,000).

Amnesty International insists that the purported “increase” in maternal mortality is caused by lack of access to medical care. Homebirth advocates insist that it has been caused by an increase in C-sections. Yet a careful analysis of the data does not support either contention.

If decreased access to healthcare were responsible for an increase in maternal mortality, we would expect that the increase would be spread evenly among all possible causes of maternal mortality, but that’s not what we find. The following graph shows maternal death rates from pre-eclampsia/eclampsia, hemorrhage, embolism (the three most common causes of maternal death) as well as other direct causes (all other obstetric complications) and indirect causes (from other medical conditions).

As the graph shows, the purported increase in maternal mortality was not spread evenly across all categories. Indeed, the most common cause of maternal mortality remained flat. In contrast, the categories that were expanded in the new reporting guidelines were responsible for almost all of the purported increase. This suggests that the “increase” reflects more comprehensive reporting, not an actual increase in maternal mortality.

The fact that hemorrhage and embolism were flat casts doubt on the idea that the increasing C-section rate is leading to increasing maternal mortality. Moreover, the C-section rate rose from 2005 to 2006, but the maternal mortality rate actually dropped.

Despite the rhetoric of Amnesty International, it is unclear whether we are experiencing a crisis of any kind, let alone a “shocking” maternal mortality rate.

saltyc

So the maternal mortality rate is not shocking, so glad we can all take comfort now, the number of deaths and morbidity are acceptable. whew.

saltyc

Wow, you mean this whole movement for reprductive rights is a ruse? So if we all just stop fighting, women will always have access to abortion no matter what so we should quit wasting our time! It’s as simple as that!